Medical providers are human, and sometimes that means they make mistakes, forget to document medical records, or do so well after the fact. And while you want to make a medical record as thorough as possible on the date of service, it’s important to know which types of medical record amendments are allowable and how to perform them.
Check out the three types of medical record amendments you may encounter, along with best practices to ensure yours are compliant.
Late Entries
A late entry is a type of medical record documentation that doesn’t happen on the date of service. It may be an entire note, or it could simply supply additional information that wasn’t included on the original note. Either way, if you need to make this type of medical record amendment, consider the following best practices.
- It should bear the current date: If you’re adding documentation to the medical record after the date of service has passed, your documentation should be dated with the current calendar date. It’s inappropriate to pretend that the record was documented on the date of service if that wasn’t the case.
- You should add it as soon as possible: Once you realize you forgot to add information to the medical record, make it a priority. You never want to get into the habit of routinely adding documentation long after the date of service.
- It should be based on the clinician’s memory: You should only add a late entry if the clinician clearly recalls the omitted information.
- The provider must sign the late entry: As with any other documentation, the provider must sign the late entry.
Addendum
You’ll add an addendum to documentation if you encounter information that wasn’t available at the time of the original medical record entry. Check these best practices for these types of medical record amendments.
- It should be done in a timely manner: If your practice is adding addenda every time a claim is denied (in an effort to meet medical necessity after the fact), then you are not in compliance. Instead, add the new information you have as soon as you receive it rather than waiting.
- It should include the current date: Never back date an addendum, always use the date you added it.
- You should always include a reason: The person adding the addendum must always state the reason for the addition or clarification of the information being added to the medical record. For instance, “patient had a subsequent series of A1C tests performed, and Dr. Smith sent over the information, confirming her diabetes diagnosis.”
- The person making the addendum must sign it: Whichever provider adds the addendum should sign it when dating it.
Corrections
If you added something to a medical record and you later realize it included an error, you can later correct the medical record. These tips can help you create compliant corrections to documentation:
- Never write over or delete the passage that was made in error: Instead, add the correction above it and draw a single line through the erroneous information. The line should be thin enough that the original entry is clearly legible.
- Sign or initial and date the deletion: The provider should sign and add the current date to the corrected entry in the note.
- State the reason for the correction: In simple terms, document why you’re making the correction. For instance, “Original entry indicated Ms. Jones has a shellfish allergy, but her allergy is actually only to shrimp.”
There’s so much more to know about medical record amendments, and legal expert Amanda Waesch, JD, is here to help. During her online training, Avoid Mistakes & Penalties When Amending Medical Records, Amanda will walk you through every step of the process to stay compliant with your documentation amendments. Register today!
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The post 3 Types of Medical Record Amendments (and How to Do Them) appeared first on Healthcare Training Leader.